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Audit and Control

for Healthcare Manufacturers
A Systems-Based Approach

Tim Sandle
and Jennifer Sandle

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DHI Publishing, LLC
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10 9 8 7 6 5 4 3 2 1

ISBN: 978-1-942911-36-4
Copyright © 2019 Tim Sandle and Jennifer Sandle
All rights reserved.

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While every effort has been made by the publisher and the authors to
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CONTENTS

1 THE PURPOSE OF AUDITING 1

Introduction 1
The Requirement for Audits 3
What are Audits? 4
Audit Evidence 14
Audits and Continuous Improvement 15
Benefits of Audits 20
The Audit Cycle 24
The Auditor Role 25
Undertaking Audits 27
Review of Audits 31
Failure to Audit 32
Summary 33
References 33
Appendix: Some Key Definitions 37

2 QUALITY MANAGEMENT SYSTEMS 43

Introduction 43
What is “Quality”? 45
History of Quality Management Systems 47
Quality Management Systems Today 49

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iv Audit and Control for Healthcare Manufacturers

Application of Risk Management 55
Audits, Reviews and Assessments 56
Quality Management Review 60
Summary 62
References 62
Appendix: Checklist for Auditors to Assess the
Quality Management System 66

3 GMP REQUIREMENTS FOR AUDITING 85

Introduction 85
Good Manufacturing Practice 87
Applicable GMPs 89
Internal Auditing and GMP 93
External Auditing 103
Summary 106
References 106

4 ISO 9001 AND THE AUDIT PROCESS 111

Introduction 111
ISO 9000 113
ISO 9001 119
ISO 9001 and Healthcare 136
ISO 9001 and GMP 137
Criticism of ISO 9001 142
Summary 143
References 143

5 DIFFERENT TYPES OF AUDITS

AND INSPECTIONS 147
Introduction 147
Conceptual Difference: Audits and Inspections 148
The Audit Initiation Process 156
Types of Audits and Inspections 156
Baseline Audits 159
Process Audits 161
Product and Service Audits 163
Systems Based Audits and Inspections 166
Documentation Audits 167
Risk Based Audits 168
Other Ways to Classify Audits 168

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Contents v
Summary 169
References 170

6 SYSTEMS-BASED AUDITS AND INSPECTIONS 173

Introduction 173
History of the System-Based Approach 175
Scientific Focus 176
Auditing Systems 176
Examination of the Systems 182
Weaknesses with the Systems-Based Approach 200
Summary 200
References 201

7 MANAGING THE AUDIT FUNCTION

AND DEFINING METRICS 205
Introduction 205
Responsibilities and Tasks of the Audit Manager 206
Senior Management 218
Metrics 220
Audit Metrics 225
Summary 239
References 240

8 AUDITOR TRAINING AND THE

CHARACTERISTICS OF A GOOD AUDITOR 243
Introduction 243
What Makes for a Good Auditor? 244
Auditor Training 247
Broad Objectives for the Auditor and Auditor Training 248
Competencies 249
The Process of Auditor Training 253
Internal or External Auditor Sourced Training 264
Questions for Trainee Auditors 265
What Auditors Need to Look For 270
Use of Visual Aids 273
Field Work – Practical Training 275
Lead Auditor 278
Training Backroom Support 279
Evaluating the Program 280
Summary 281
References 281

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vi Audit and Control for Healthcare Manufacturers

9 INTRODUCTION TO RISK MANAGEMENT 285

Introduction 285
Regulatory Approaches 287
The Basics of Risk Assessment 294
Advantages and Disadvantages of Risk Assessment 297
Approaching Risk Assessment 298
Assessing Risks 300
Quality Risk Management and Risk Assessment 305
Challenges of Risk Assessments 309
Role of Audits 314
Summary 315
References 316

10 RISK BASED APPROACH TO

QUALITY AUDITING 321
Introduction 321
Quality Audits 324
Audit Planning 326
Vertical and Horizontal Audits 328
Risk and the Audit Process 328
Conducting Audits 336
Assigning Non-Compliances 337
Audit Responses 338
Management Oversight and Review 339
Summary 340
References 340

11 AUDITOR TECHNIQUES 343

Introduction 343
Planning Audits 344
Time-Focused 347
Techniques for Conducting Audits 347
Summary 365
References 366

12 THE ROLE OF THE AUDITEE:

RUNNING AND RESPONDING TO AUDITS 367
Introduction 367
Preparing for the Audit 368
Being Audited – The Auditee’s Role in the Audit Process 372

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Contents vii
Interacting with the Auditor 373
Replying to Questions 374
Use of Runners 377
Running the Backroom 377
Attending the Closing Meeting 378
Types of Audit Findings 380
Responding to Audit Reports 385
Summary 393
References 393

13 DOCUMENTING AND REPORTING AUDITS 395

Introduction 395
What is an Audit Report? 396
Purpose of the Audit Report 397
Expressing Opinions 399
Writing Styles 404
Setting Corrective and Preventive Actions 409
Structuring the Report 413
Issuing the Report 427
Non-Conformity Reports 429
Summary 429
References 430

14 BEST PRACTICES FOR LABORATORY

OOS INVESTIGATIONS 433
Introduction 433
Differences in Terminology 434
Where did OOS come from? 436
The Need to Refresh the Guidance 438
Conducting OOS Investigations 439
New Ways of Looking at the OOS Investigation 444
Case Study 452
Summary 453
References 454

15 MICROBIAL DATA DEVIATIONS 457

Introduction 457
Microbial Data Deviations 460
Out of Limits and Out of Specification 462
Levels of Investigation 466

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viii Audit and Control for Healthcare Manufacturers

Gathering Evidence 467
Additional Data 472
Risk Assessment 473
Root Causes 474
Corrective and Preventive Actions 479
Action Memoranda 481
Investigation Reports 481
Revisiting Microbial Data Deviations 482
Summary 482
References 483

16 CONTROL AND USE OF

REFERENCE STANDARDS 485
Introduction 485
What are Reference Standards and why are they used? 486
Different Types of Reference Materials 488
Standards for Reference Materials 492
Preparing Reference Materials 497
Assessment of Reference Materials 499
How Reference Standards are used 500
Summary 503
References 503

17 AUDITING STERILE PHARMACEUTICAL

FACILITIES 507
Introduction 507
Facilities 508
Cleaning and Disinfection Regimes 518
Utilities 520
Processing 525
Manufacturing 529
Sterilization 531
Product Filling 541
Personnel 546
Quality Control Tests 547
QC Laboratory Testing 556
Batch Review 560
Current Technologies 560
Summary 562
References 562

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Contents ix
Appendix: Sterile Manufacturing: A Checklist
for Inspection Preparation 568

18 SELF-INSPECTION IN PHARMACEUTICAL
FACILITIES AS A CASE STUDY 577
Introduction 577
Audit Plan 579
Audit Criteria 579
Audit Checklist 580
Summary 594
References 595

19 DRAFT EXTERNAL AUDIT REPORT FOR

ASSESSING A MANUFACTURER FOR PRIONS 597
Introduction 597
Example Report 600
Summary 605
References 606

20 COMPUTERIZED SYSTEMS AUDITS AND

DATA INTEGRITY REQUIREMENTS 607
Introduction 607
Computerized Systems 610
Computerized Systems Audits 611
Supplier 612
Ownership 612
Compliance Standards 614
Computerized System Validation 615
What to Audit? 622
Five Step Approach 638
Significant Non-compliances 640
Data Integrity 640
Data and Data Governance 643
Regulatory Perspectives 645
Risks 649
Risk Assessment 652
Vendor Questionnaires 655
Summary 660
References 662

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x Audit and Control for Healthcare Manufacturers

21 AUDITING CLEANROOMS IN
PHARMACEUTICAL FACILITIES 667
Introduction 667
Space and Design 668
Process Flow 670
Certification 670
Physical Operations 671
Equipment 675
Personnel 676
Aseptic Processing 678
Cleaning and Disinfection 680
Environmental Monitoring 683
Cleanroom Documentation 686
Data Integrity 688
Energy 689
Summary 690
References 690

22 AUDITING CULTURE MEDIA SUPPLIERS 693

Introduction 693
Culture Media Manufacture Quality Standards 694
The Audit Process 696
Scope of Audits 698
Key Focal Points for Auditing Culture Media Manufacturing
Facilities 699
Post-Tour and the Examination of Specific Areas
in Further Detail 707
Summary 714
References 715

23 AUDITING AND CONTROL OF THE

LABORATORY FUNCTION 719
Introduction 719
What Makes for the Good Laboratory? 721
Auditing the Laboratory 722
Summary 748
References 748

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Contents xi

24 AUDITING THE MICROBIOLOGY

LABORATORY 751
Introduction 751
Good Housekeeping 752
Sampling and Sample Receipt 753
Culture Media 755
Microbial Cultures 757
Microbial Identification 759
Laboratory Water 761
Control of Regents 761
Microbiology Laboratory Equipment 761
Control of Consumables 764
Method Validation and Qualification 765
Test Controls 765
Bacterial Endotoxin Testing 766
Water Testing 766
Sterility Testing 767
Microbiology Laboratory Cleaning 770
Antibiotic Assays 771
Disinfectant Efficacy Testing 771
Environmental Monitoring 772
Biological Indicators 773
Method Verification 774
Out-of-Specification Procedures 775
General Documentation 776
Data Control and Data Integrity 779
Training 782
Biosafety 784
Proficiency Testing 785
Waste Management 786
Change Areas 786
Space Utilization and Improving Laboratory Design 787
Resourcing 791
General Checklist 791
Summary 794
References 795

25 AUDIT TEMPLATES 799

Introduction 799
Audit Plan 800
Audit Note Taking 804

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xii Audit and Control for Healthcare Manufacturers

Audit Checklist 805
Supplier Audit Checklist 813
Audit Report 835
Closure Letter 837
Summary 839

INDEX 841

ABOUT THE AUTHORS 847

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